Abstract

The NHS has introduced the two week wait scheme to detect upper gastrointestinal cancers at an early stage and improve survival
rates The aim of this study was to assess the impact of this scheme and changes in endoscopy waiting times on tumour stage
and resection rates over a four year period. Data were analysed prospectively for all patients diagnosed with oesophagogastric
cancer between September 1998 and September 2002 and from those referred under the two week wait scheme since its introduction
in 2000. Of those tumours diagnosed by this scheme (15%) only 5% were early disease (stage 1 or 2). Patients with early cancer,
mainly diagnosed by routine gastroscopy, do not present with symptoms meeting the two week wait criteria. An increase in the
resection rates for early disease will most probably be seen with a reduction in routine endoscopy waiting times.

Early diagnosis and treatment of cancer is widely accepted to improve prognosis in oesophagogastric cancer. The past few years
have seen increased political and public pressure to improve the service for cancer patients in the UK. This has followed
concerns that theUK lags behind Western Europe in terms of cancer survival. This is particularly pronounced in gastric cancer.1 One possible reason for poor cancer survival in the UK is the delayed access to specialist clinical and diagnostic services
within the NHS for patients with suspected cancer resulting in delayed treatment (the average time to see a consultant has
been seven weeks, with three quarters of people getting an outpatient appointment within 13 weeks of the GP requesting one).2

The current UK government plan to tackle this issue has led to the introduction of the two week wait scheme. This measure
was included in the government white paper The new NHS—Modern, Dependable published in December 1997. This proposes that patients with suspected cancer should be able to see a specialist within two
weeks of their GP referring. These arrangements were implemented nationally for upper gastrointestinal cancers in July 2000.

There are about 17 000 new cases of oesophageal and gastric cancer each year in the UK. These cancers have a particularly
poor survival rate in part because of late stage at diagnosis. To assist appropriate referrals by GPs a list of guidelines
and criteria for urgent referral (box 1) has been developed by the Department of Health (DoH), based on the published literature
and the unpublished audits of symptoms in patients presenting with upper gastrointestinal (GI) cancer.

Box 1
Urgent referral guidelines

Dysphagia (any age)

Jaundice

Upper abdominal mass

Dyspepsia plus one or more of the following: significant family history; pernicious anaemia; peptic ulcer surgery over 20
years ago; known dysplasia, atrophic gastritis, intestinal metaplasia

Dyspepsia in a patient aged 55 years or more with onset of less than one year or continuous symptoms since onset

Dyspepsia combined with one or more of the following “alarm” symptoms:

weight loss

proven anaemia

vomiting

The two week wait scheme for oesophagogastric cancers was introduced to our institution in September 2000. Significant service
improvements at the same time permitted the introduction of two full time nurse endoscopists. Our aim was to assess the validity
of the referral guidelines in terms of new cancer diagnosis within the patient population referred under the scheme. We have
also looked at the impact of the two week wait initiative and the changes in endoscopy times on tumour stage at resection
and cancer resection rates over a four year period.

METHODS

We analysed prospectively collected data on all oesophagogastric cancer patients presenting to the Norfolk and Norwich University
Hospital upper gastrointestinal surgical department for two years before and after the introduction of the two week wait scheme.
Specifically we looked at resection rate, tumour stage at resection, presenting symptoms, method of referral, and endoscopy
waiting times.

To assess the number of new gastric and oesophageal cancers detected through the two week initiative as a proportion of all
new cancers detected during the study period the details of all other patients with a new diagnosis of oesophageal or gastric
cancer were obtained from the cancer audit database. These patient details were matched by hospital number with the theatre
information database (ORSOS) to determine the resection rate among this group of patients and also permit comparison with
the two week wait initiative group. The clinical notes were obtained for all patients undergoing resection.

Standard practice after referral, either on or off two week wait scheme was to arrange for an initial gastroscopy for diagnosis.
After diagnosis all patients were staged by multislice computed tomography, endoscopic ultrasound (oesophageal and cardia
tumours only), and laparoscopy (potentially resectable gastric tumours only). Stage 2 and 3 oesophageal and cardia tumours
were offered neoadjuvant chemotherapy. Surgery was offered to patients staged 1–3 providing adequate fitness. Cancer stage
was confirmed from histological reports after resection and also using both the histology and radiology (ISIS) database. Results
were divided into two years before and two years after introduction of the two week wait scheme and analysed statistically
where appropriate using χ2 test.

RESULTS

During the four year period a total of 494 patients were diagnosed with oesophagogastric cancer; 247 before the introduction
in the two years and exactly 247 after.

Before the introduction of the scheme the curative resection rate was 38% (94 of 247). After scheme introduction this increased
to 48% (118 of 247) (odds ratio 1.48, 95% CI 1.03 to 2.11) (fig 1). The number of curative resections for early stage disease
(stage 1 and 2) rose correspondingly from 47 to 58.

Changes in resection rates by histopathological stage in the two years before the introduction of the two week scheme and
two years after.

In the two years after the scheme introduction there were 623 referrals under the two week wait scheme for oesophagogastric
cancer of which 38 were found to have cancer (6% of two week wait referrals, 15% of cancers). Of the 38 patients diagnosed
with oesophagogastric cancer under the two week wait scheme only two (5%) had early stage disease compared with 56 (27%) diagnosed
outside scheme.

Examining presenting symptoms in 55 patients with early disease showed that 19 patients (35%) had symptoms that fulfilled
the criteria of the two week wait scheme. However, only two of these patients were referred via this route. Box 2 shows the
presenting symptoms in patients with early disease.

Box 2
Presenting symptoms in patients with early disease

19 patients with urgent referral criteria

6 urgent admissions with frank bleeding

13 with anaemia only

10 with dyspepsia only

1 with vomiting only

3 with combinations (weight loss, anaemia, vomiting)

1 from screening

There was a steady decline in routine endoscopy waiting times during the same period. This corresponded with a rise in the
number of endoscopies performed (fig 2) after the introduction of nurse endoscopists.

DISCUSSION

We have seen a substantial increase in the curative resection rate for oesophagogastric tumours in our unit since the introduction
of the government’s two week wait scheme. This has corresponded with a rise in the early stage cancers over the same period.
However, it would seem that this link is only circumstantial. From the large number of patients referred under the scheme
disappointingly only two had early stage disease. This suggests that the two week wait scheme is probably not the reason for
the observed improved resection rate.

Early diagnosis and subsequently definitive treatment were facilitated by early referral by GPs and a multidisciplinary team
approach, but primarily by the introduction of nurse endoscopists, which coincided with introduction of the two week wait
scheme. This led to a considerable reduction in routine endoscopy waiting times and consequently to an increased resection
rate.

The signs and symptoms listed on the two week wait scheme for upper GI cancers are those commonly seen with late stage disease
rather than early. This would explain why most cancers diagnosed in our unit through the scheme were late stage. In contrast,
although alarm symptoms consistently predict serious upper GI abnormality, a significant proportion of patients with upper
GI cancer will have no alarm symptoms.3

Our findings support those of previously published audits at other units.4–6 The poor cancer pick up rate (4%–15%) might reflect poor specificity of the referral criteria or a high degree of inappropriate
referrals.7 These few cases of cancer detected under the scheme have advanced disease with most of the new cancers diagnosed outside
the scheme. Furthermore, the “two week rule” has led in many cases to a significant increase in referrals for endoscopy with
a potential adverse effect on the routine non-urgent waiting times.8

Improving outcomes in patients with oesophagogastric cancer in the UK may be achieved by earlier diagnosis; patients with
stage 1 or 2 disease are most likely to benefit from surgery. The two week wait scheme would only have identified 35% of our
patients with early stage disease even if scheme utilisation was 100%.

This work suggests that the two week wait scheme is unlikely to improve survival figures for oesophagogastric cancers in the
UK. It may well be that improving resources for routine endoscopy will be of more benefit.